The world is struggling with the new and uncertain realities of the COVID-19 pandemic, which has challenged all facets of the healthcare system in unprecedented ways. As the initial experience in the United States has taught us, none are more vulnerable to COVID-19–related morbidity and mortality than the ESRD population (1). These individuals carry a high burden of comorbidity, may be immunocompromised, have high rates of healthcare use, and often have a high prevalence of many of the symptoms that overlap with those of COVID-19. Moreover, the risk of viral transmission may be greatest for patients receiving in-center hemodialysis because of the scheduled frequent trips for dialysis treatments within healthcare facilities, limited distancing between patients, and frequent interactions with healthcare workers.
Taken together, these factors create many challenges in ongoing nationwide efforts to limit the transmission of the SARS-CoV-2 virus. As a result, robust infection prevention and control policies and procedures are needed in the care of ESRD patients and have been developed with guidance from the Centers for Disease Control and Prevention (CDC) and in collaboration with local infection prevention and control authorities. These measures must be implemented and adhered to while being subjected to ongoing revision, both in the face of emerging evidence and in an evolving climate of supply chain disruptions, particularly those resulting from shortages of personal protective equipment (PPE).
By virtue of receiving dialysis treatments at home, both peritoneal dialysis (PD) and home hemodialysis (HHD) patients remain somewhat at an advantage over their in-center hemodialysis counterparts. Home dialysis patients may be better able to adhere to social distancing measures, with fewer interactions with healthcare workers. The COVID-19 pandemic has further underscored the additional potential advantages of increasing home-based ESRD care. It is possible that the long-lasting impact of COVID-19 may serve to further bolster ongoing efforts such as the Advancing American Kidney Health Executive Order in increasing the use of home dialysis in the United States.
Despite the advantages of home dialysis therapy during the COVID-19 pandemic, there are undoubtedly many challenges that patients, care partners, and healthcare providers are facing to ensure that home dialysis treatments remain uninterrupted and that care remains of the highest quality. Efforts to limit healthcare treatment team encounters to minimize the risk of COVID-19 transmission must be carefully balanced against any potential deleterious adverse health consequences that may ensue as a result. In this regard, and in an effort to provide guidance, education, and advocacy for the care of patients receiving home dialysis during this time, the American Society of Nephrology (ASN) COVID-19 Home Dialysis Subcommittee was formed. Composed of representation from the Nephrologists Transforming Dialysis Safety (NTDS) initiative, the CDC, dialysis organizations, home dialysis vendors, nurses, home dialysis patients, and ASN’s policy team, our subcommittee operates within a larger ASN-wide effort that is responding to the COVID-19 pandemic across the continuum of kidney care: the ASN COVID-19 Response Team. Among the main purviews of this subcommittee are the following:
1 Advocate for governmental, surgical, and hospital administration policies to ensure that access procedures (i.e., PD catheter insertion, HHD access placement) are not delayed for patients who choose and are in urgent need of home dialysis therapy initiation. Explore the role of percutaneous PD access insertion under the operating room resource limitations imposed by COVID-19.
2 Address potential temporary staffing shortages so as not to limit home dialysis patient training in advocating for policies that expand the eligible pool of nurses able to care for and train patients receiving home dialysis. For example, in the context of the COVID-19 pandemic, advocate for state licensure waivers and waivers by the CMS to temporarily allow registered nurses (RNs) with fewer than 12 months of dialysis experience (but no fewer than 6 months) to be trained and allowed to provide PD training to patients, provided those RNs are working in a facility with at least one RN who has completed at least 12 months of dialysis training.
3 Explore greater use of urgent-start PD and other pathways to allow for a timely transition to home dialysis in an effort to avoid and limit exposure in dialysis facilities.
4 Work with CDC and NTDS to disseminate best demonstrated practices in terms of caring for COVID-19–positive home dialysis patients and reducing the risk of COVID-19 transmission between staff and home dialysis patients and care partners, during clinic visits, laboratory or intercurrent problem visits, patient training, and home visit encounters. These may include appropriate hand hygiene techniques, use of screening measures, use of PPE by patients and facility staff when in the facility and during home visits from dialysis staff, and information regarding testing and care of suspected or confirmed COVID-19–positive patients and/or care partners.
5 Although policies for telehealth have been well established for the care of home dialysis patients, the CMS has made possible significant expansion in the use of telehealth during the COVID-19 pandemic for patients with ESRD. This task force will continue to clarify how these policies apply to telehealth visits for patients receiving home dialysis; what waivers are necessary to support telehealth; which communication means may be used, particularly for patients without internet or smartphone access; and, where possible, advocate for further expanded coverage for telehealth visits while providing guidance and a framework for their optimal conduct.
6 Work with home dialysis vendors to ensure that home dialysis supplies are readily available and are delivered to patients in a way that ensures the safety of patients, their care partners, and delivery personnel.
7 Ensure that education is provided regarding the appropriate disposal of dialysis supplies and dialysis effluent by COVID-19–positive patients performing treatments at home, using the latest available evidence and guidance from the CDC.
8 Address potential and actual PPE shortages by developing mask reuse and conservation strategies for patients who use them during routine PD exchanges and HHD on/off procedures within the home. Reevaluate the policies for the use of masks during routine PD exchanges under constraints of impending or actual mask shortages.
9 In the face of COVID-19, the CMS has already made exceptions in reporting of quality measures and deadlines for a range of programs. Within these policies we seek to provide additional guidance highlighting more judicious use and appropriateness of deferment of various laboratory measures, peritoneal membrane evaluation, and measures of dialysis adequacy (i.e., kt/v urea). We aim to keep the kidney community abreast of any policy changes or infection prevention and control measures that may have a direct impact on the care of home dialysis patients while providing a forum to address questions pertaining to the care of these patients during the COVID-19 pandemic in a timely fashion, using the latest available evidence.
It is our hope that the task force will help facilitate the implementation of and adherence to the best demonstrated practices for the care of home dialysis patients during the COVID-19 pandemic across dialysis facilities in the United States, serving as a resource for credible and time-sensitive information based on sound scientific principles during these challenging times. In addition, the COVID-19 pandemic will leave a long-lasting mark on the home dialysis community in the United States, serving as a catalyst for much-needed refinements in the care model for delivery of home dialysis, future pandemic planning and emergency preparedness, improvement in access to and enhancement of telehealth delivery, and refinement of infection prevention and control measures for home dialysis facilities, all the while improving access to home-based ESRD care.
The authors thank the ASN COVID-19 Response Team Home Dialysis Subcommittee members who contributed to this article: Michael A. Kraus, Kerry A. Leigh, Rajnish Mehrotra, Alicia Neu, Matthew Oliver, Jeffrey I. Silberzweig, Bradley A. Warady, Suzanne Watnick, and Caroline Wilkie.
Watnick S, McNamara E. On the frontline of the COVID-19 outbreak: Keeping patients on long-term dialysis safe [published online ahead of print March 28, 2020]. Clin J Am Soc Nephrol doi: 10.2215/CJN.03540320.